Agenda - Environmental Policy Board - 02/03/2014

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Nominee: Indicate Mr., Mrs., Ms., Miss ❑ Youth (18 and under) 2013 City of Elk River Volunteer of the Month Award Official Nomination Form ❑ Senior (55 and over) ❑ Group Today's Date: Applications are valid from 6 months from the time of submission Name: Address: City: State: Zip: Daytime Phone Number: Email address: Please check the appropriate age classification for your nominee: ❑ Young Adult (19 -25) ❑ Adult Verification: To qualify, the nominee must have one reference who may be contacted to verify the scope and extent of the nominee's activities. Reference should be a person familiar with the community service activities for which the nomination is made and should not include either the nominee or any persons related to the nominee. The reference below must be someone other than the nominator. Reference: Name: Daytime Phone Number: Address: City: State: Zip: Agency /Organization: Nominator: Name: Daytime Phone Number: Address: City: State: Zip: Agency /Organization: Signature: n: \public bodies \city council \council \mayor \dietz \mayors volunteer of the month award.docx